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Managing immunization stress-related response: A contributor to sustaining trust in vaccines C Meghan McMurtry1,2,3,4*
This work is licensed under a Creative Commons Attribution 4.0 International Abstract License.
Adverse events following immunizations (AEFI) are important to identify and manage effectively so as to sustain trust in vaccines and optimize health. The AEFI category related to “anxiety about the immunization” was considered problematic as it did not adequately Affiliations capture the range of stress responses that can occur. The currently used term for this category, 1 Department of Psychology, immunization stress-related responses (ISRR), is broader, including the full spectrum of signs University of Guelph, Guelph, ON and symptoms that can arise in response to stress. ISRR can include vasovagal reactions 2 Pediatric Chronic Pain Program, (fainting), hyperventilation and functional neurological symptoms (e.g. weakness, nonepileptic McMaster University, seizures). It is based on a biopsychosocial framework in which biological (e.g. age, sex), Hamilton, ON psychological (e.g. preparedness, previous experiences, anxiety) and social factors (e.g. 3 Adjunct Research Professor, Department of Paediatrics, response by others, social media) interact to create an individual’s stress response to the Western University, London, ON immunization process. 4 Associate Scientist, Children’s Health Research Institute, New guidance is available on prevention, early detection and management of ISRRs which is London, ON summarized in the article.
Suggested citation: McMurtry CM. Managing immunization stress-related response: A contributor to sustaining *Correspondence: trust in vaccines. Can Commun Dis Rep 2020;46(6):210–8. https://doi.org/10.14745/ccdr.v46i06a10 [email protected] Keywords: vaccine, immunization, stress, fear, pain, syncope, fainting Introduction
Vaccines are a clear public health success story, protecting This is the fifth article produced by the Canadian Vaccination people from a number of diseases. Adverse events following Evidence Resource and Exchange Centre (CANVax) in the immunizations (AEFI) are important to identify and manage CANVax Briefs series. Multidisciplinary professionals at appropriately so as to sustain trust in vaccines and optimize CANVax identify and develop useful resources to foster vaccine health. In 2015, the Global Advisory Committee on Vaccine uptake (4,5). Safety of the World Health Organization (WHO) brought together an Expert Working Group to discuss what was ISRR as part of AEFI previously known as an “AEFI arising from anxiety about The safety of vaccinations is monitored globally, and AEFI, the immunization.” Following review by the Global Advisory including events that are seen as arising from “anxiety” about Committee in 2017 and 2018 and endorsement by the Strategic the immunization, are grouped into five different categories Advisory Committee for Vaccine Safety in April 2019, a detailed (6). Naming these “anxiety reactions” is problematic for two guidance manual for healthcare professionals, Immunization reasons: anxiety does not paint an accurate or complete picture stress-related response: a manual for program managers of what can be quite complex; and this description is indicative and health professionals to prevent, identify and respond to of a biomedical lens that classifies physiological responses as stress‑related responses following immunization, was published “physical” versus “psychological,” which does not take into (1) along with a synopsis (2) and a peer-reviewed publication (3). account that each individual’s mind and body are intricately connected (1). The guidance manual provides details on understanding, preventing, identifying and managing what are now termed The term immunization stress-related responses (ISRR) “immunization stress-related responses,” or ISRR (1). acknowledges the full spectrum of signs and symptoms experienced in response to stress: vasovagal reactions (fainting), The objective of this paper is to briefly describe ISRR, direct hyperventilation, and functional neurological symptoms readers to detailed guidance on the topic and provide an (e.g. weakness, nonepileptic seizures), among others. The overview of prevention and management. biopsychosocial framework helps to understand that biological (e.g. age, sex), psychological (e.g. preparedness, previous
Page 210 CCDR • June 4, 2020 • Vol. 46 No. 6 CANVax - www.canvax.ca SERIES experiences, anxiety) and social (e.g. peer behaviour and vasovagal reaction can present before, during or immediately experiences, social media, community trust in health care) factors after immunization, usually within five minutes (1). interact to develop an individual’s stress response and ISRR (1). DNSRs are characterized by neurological symptoms with no ISRR and other AEFI require different prevention and treatment physical findings, otherwise known as functional neurological responses. For example, it is important to distinguish ISRR symptoms (19,20). Symptoms can include difficulty walking or from anaphylaxis, which is life‑threatening and requires moving a limb, weakness, tingling sensations in the muscles urgent recognition and a particular pharmacologic response and nonepileptic seizures. These symptoms are considered (intramuscular epinephrine) and expert management. ISRR is involuntary. DNSRs have not been well documented or reported neither life-threatening nor helped by epinephrine, and requires in individuals following immunization, but there are reports of different management. “masses” or “clusters” of these reactions in multiple people in close proximity (21). The current evidence suggests that DNSRs The role of the immunization process result from complex multifactorial etiologies (22). DNSRs most Immunizations are typically delivered through injections. commonly occur independently of immunization; a DNSR that The process has several characteristics that can increase develops after an immunization is best understood using a distress: pain from the injection, fear, sight of a needle, sight biopsychosocial framework in which the immunization process is of blood, prolonged standing and responses by others in the one of a number of contributing factors (1). environment (1,7). Children and adolescents are particularly at risk as immunizations are common at this age. Pain and fear A variety of postimmunization events, syndromes and disorders can go hand in hand: the more scared an individual is about a have been reported that have no confirmed relationship needle, the more pain they report feeling (7,8). Most people with immunization (1). These include complex regional pain who have high levels of needle fear report a previous negative syndrome (CRPS) type 1 with delayed onset; chronic fatigue experience (7,9–11). syndrome; postural orthostatic tachycardia syndrome (POTS); and dissociative neurological symptom disorders (also known There are short and long-term consequences of needle fear. In as conversion disorders) with delayed onset. They are not the short-term, individuals may require longer procedure times, considered to be ISRR (1). have an increased risk of fainting, try to run away and experience greater distress and pain (7,8,10,12). Fear of the procedure Acute stress response, vasovagal reaction and DNSR in can develop in the long-term along with fear of healthcare individuals or “clusters” of individuals can occur independent of professionals, avoidance of medical procedures, vaccine immunization. They have also been reported after immunization. hesitancy and lack of benefit from traditional pain management WHO uses a detailed causality process to determine techniques (7,8,13–15). whether there is any relation between the symptoms and the immunization (6); more details can be found in the WHO ISRR Identification of ISRR: Timing and guidance manual (1). ISRR are not caused by the vaccine, a manifestation defect in vaccine quality or an error in the immunization program or process. Understanding and recognizing ISRRs is key to facilitating prevention and appropriate management of this category of Each person who comes to be immunized has their own history, AEFIs. While other AEFIs occur only after immunization, an ISRR psychological strengths and vulnerabilities, and perceptions of can occur immediately before, during or after immunization (1,6). the procedure and social context. Experiencing an ISRR is not the The manifestations are acute stress responses, vasovagal person’s fault (1). Figure 1 illustrates ISRR in individual and group reactions or dissociative neurological symptom reactions contexts (1). (DNSRs) (1). An acute stress response (“fight–flight–freeze” response) can vary in severity, from “butterflies in the stomach” and low to moderate levels of worry to more severe responses Facilitating prevention and appropriate including difficulty breathing or rapid breathing/hyperventilation intervention of ISRR with tingling in the fingers and toes and increased heart rate (1,16,17). A vasovagal reaction is a fainting response that Prevention can cause a range of effects, from feeling mildly dizzy to losing Prevention relies on targeting predisposing risk factors. Clinicians consciousness due to insufficient blood flow to the brain (18). should be educated on ISRRs, their prevention, screening and management (1). Brief reminders/educational materials on An acute stress response may be followed by a vasovagal display in immunization clinics, for example, a poster describing reaction after a sudden decrease in heart rate and a drop in the difference between anaphylaxis and ISRR, could be helpful. blood pressure. Headache and nausea can also accompany As social media can play a particularly strong negative role in stress reactions (1). Symptoms of an acute stress response and mass immunization contexts, including school immunization programs, communication is important before, during and after
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Figure 1: ISRR in individual and group contexts BEFORE IMMUNIZATION (PREDISPOSING)
SOCIAL BIOLOGICAL MEDIA SOCIAL - Age - Genetics - Receive negative info from family, (e.g. re: vasovagal response) friends, media, others - Low body mass - Witnessing others’ negative reactions PSYCHOLOGICAL - Cultural beliefs - Previous negative needle experiences - Anxiety re: vaccination, medical situations - History of acute stress response
IMMUNIZATION CONTEXT (PRECIPITATING)
SOCIAL BIOLOGICAL INDIVIDUAL MASS SOCIAL MEDIA - Prolonged standing - Vasovagal response - Witnessing peers’ - Pain experience adverse reactions - Behaviour, attitude of PSYCHOLOGICAL others in context - Personal expectations - Pain expression in - Fear front of peers - Pain experience SOCIAL PSYCHOLOGICAL - Behaviour/attitude of Concerns re: evaluations healthcare providers and from peers, authority caregivers figures - Pain expression
ACUTE STRESS RESPONSE AND VASOVAGAL REACTION • Dizziness • Vasovagal syncope • Heart racing • Nausea • Blurred vision • Sweating • Hyperventilation
AFTER IMMUNIZATION (PERPETUATING)
BIOLOGICAL SOCIAL SOCIAL MEDIA - Ongoing cascade of stress response symptoms - Behaviour, confidence, attitude of - HPA axis sensitization others (e.g. healthcare providers, authorities, family, peers, community) PSYCHOLOGICAL - Media - Catastrotphic interpretation - Fear - Hypervigilance to bodily experiences DISSOCIATIVE NEUROLOGICAL SYMPTOM REACTION (DNSR)
Abbreviations: HPA, hypothalamic-pituitary-adrenal; ISRR, immunization stress-related response There are three broad time points: before the immunization (historical, predisposing factors); in the immunization context (precipitating factors, initial response); and after immunization (delayed response influenced by perpetuating factors) Risk factors: shapes with a patterned fill show examples of potential risk factors for an ISRR; gear shapes show the dynamic interactions between risk factors Progression: the person being immunized is shown at different times with example risk factors leading to a cascade of symptoms (initial response, ongoing) consistent with ISRR. However, not everyone progresses step-by-step from one stage to the next. For example, a dissociative neurological symptom reaction (DNSR) does not need to follow an acute stress response Social media’s potential to provide negative information is highlighted Source: Immunization stress-related response: a manual for program managers and health professionals to prevent, identify and respond to stress-related responses following immunization (1)
Page 212 CCDR • June 4, 2020 • Vol. 46 No. 6 CANVax - www.canvax.ca SERIES the immunization to reduce the risk of ISRR (23). Planning for Table 1: Questions to ask to screen for high levels of mass immunizations should take into account existing rates of needle fear ISRR and vulnerability factors, that is, the age and sex of the Age recipients because adolescents and females are at greater risk of group, Question a vasovagal reaction (24). Therefore, planning for immunization years clinics should include familiarizing healthcare providers with how 5–8 1) How afraid of needles are you? Not at all; a little bit; a to screen, prevent and manage vasovagal reactions (1). Targeted medium amount; a lot; very, very much/most possible? education sessions teaching coping strategies can also be 2) Do you try hard to miss having a needle because you helpful (25,26). are so scared? Older than 1) How afraid of needles are you? Not afraid; a little bit; In every clinic, environmental strategies can reduce risk factors 8 a moderate amount; a lot; or the most afraid possible? for ISRR. The immunization environment should be at a 2) Do you think this level is higher than it should be (or comfortable temperature (rather than overheated) and those higher than that of most of your friends)? at risk of an ISRR should be vaccinated in private (1). The flow 3) Do you avoid getting needles because you are afraid? of individuals through the clinic should be such that the waiting area has only a few people (i.e. should not be crowded) and Universal interventions no one should be waiting for long. Allowing space to sit rather All recipients should be shown age-appropriate ways to manage than having to stand for a long time is helpful. To build trust, the pain and low to moderate fear (1,27). See Table 2 for physical, healthcare team should be calm, confident and friendly and able psychological, procedural and pharmacological strategies to communicate well with the recipients and any caregivers; they recommended for different age groups. A supportive caregiver will also need to address any caregivers who are nervous and could also be present to help with coping strategies. For further exacerbating fear in the vaccine recipient (1). details see Reducing pain during vaccine injections: clinical practice guideline (27). Screening People at high risk for ISRR should be identified by screening for Targeted interventions for ISRR high levels of needle fear and previous negative experiences with If an individual is at elevated risk for an ISRR, additional measures needles, including fainting (1). For school vaccination campaigns, need to be put in place, such as avoiding having them wait in teachers, school nurses or other staff may be able to flag the general waiting area, immunizing them at the beginning of students at high risk for ISRR ahead of time, or individuals may the clinic and immunizing them in private (1). These strategies self-identify. Late school-age and adolescent youth appear to be are designed to reduce contagion of fear and other negative at higher risk of ISRR than other age groups. Individuals with a emotions as well as to contain any negative effects of an ISRR, history of vasovagal reactions, including syncope and/or a high should one occur. These individuals may benefit from having a level of needle fear may be particularly at risk. Individuals with calm, supportive caregiver or friend with them; as noted above, a preexisting anxiety disorders and/or developmental disorders fearful caregiver or friend can exacerbate the situation and they (including autism spectrum disorder) may also need extra time need to be addressed immediately (1). and care (1). If an individual’s level of fear is high but they are not avoiding Each vaccine recipient should be asked if they have ever fainted the vaccination, two approaches could be used: first, identify (i.e. lost consciousness) and/or had prodromal symptoms (e.g. what can be done in the immunization clinic to create a felt dizzy, nauseated and/or clammy and/or saw spots) before, positive experience for the individual, for example, taking during or after a needle procedure (1). Individuals who have a more time, making further environmental modifications, etc.; history of vasovagal reactions should be immunized in a seated and second, determine whether treatment of the needle fear or supine position and only move to sitting (from supine) or by a mental health professional outside of the immunization standing (from sitting) if there have no signs of a vasovagal context is necessary before future immunizations (1,28). If reaction. Ideally the individual should stay seated for 15 to 30 high levels of needle fear and avoidance are present, consider minutes following the procedure, and the healthcare provider delaying the needle to address these factors. For extreme fear, should monitor them for signs of a vasovagal reaction (1). In pharmacological strategies (e.g. anxiolytics, sedations (1)) could addition, the muscle tension technique can be taught to and also be considered if the expertise is available. used by the recipient (see Targeted Interventions for ISRR). If the individual is at risk for a vasovagal reaction, immunizing Although no current gold standard exists for screening for them in a reclining or supine position while they are using the high levels of fear, it is recommended that healthcare providers muscle tension technique can be helpful (1). Muscle tension ask vaccine recipients the questions shown in Table 1 (27). keeps an individual’s blood pressure up and prevents the Caregivers can be asked similar questions about their precipitous drop that can lead to a faint. This technique has been younger children. recommended for those aged seven years and older (adolescents are at greater risk for vasovagal syncope) (27,28). First, the
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Table 2: Strategies for managing vaccine-related pain and fear in different age groups Infant Adolescent Preschool School-aged Adult Type of strategy Newborn (1–35 (13–18 (3–5 years) (6–12 years) (19 years+) months) years) Procedural Inject into anterolateral thigh – – – – (1–11 months) No aspiration when injecting (or Give most painful vaccine last simultaneous injection 0–1 year) Physical Skin-to-skin (kangaroo care) before, during, – – – – – after Cradled in parent’s arms – – – – Breastfeeding before, during, after OR sweet- tasting solutions before and/or nonnutritive – – – – sucking before, during, after Seated uprighta – – External vibrating device with cold – – – Communicationb and psychological Calm voice, simple language Don’t say it won’t hurt Use neutral words to signal procedure (e.g. “1, 2, 3, here we go”) Avoid repeated excessive reassurance (e.g. “it’s okay, it’s okay, it’s okay”) before, during, after Talk about things other than the procedure (verbal distraction) before, during, after (e.g. toy, (e.g. video video with (e.g. blowing game, video, Distraction (age appropriate) – adult coaching – – bubbles, toys, blowing to pay video, singing) bubbles, toys, attention to music) distractor) Breathing strategy – – (breathing (breathing – (cough, with toy) with toy) breath-hold) Pharmacological Topical anesthetic applied before (check – product instructions for time)c Vapocoolant spray right before – – – – – Abbreviations: , recommended strategy for a particular age group; –, strategy is not recommended for a particular age group a Individuals with a history of vasovagal reaction should be immunized in a seated or supine position and only move to sitting (from supine) or standing (from sitting) if there have no signs of a vasovagal reaction b The communication strategies for newborns and young infants are primarily directed to the caregiver c Topical anesthetic should be used when feasible; for adolescents and adults, topical anesthetic may be used if resources are available and the person is at high risk for an immunization stress-related response (ISRR)
individual tenses their major muscle groups (e.g. abdomen, legs, not fully relax. They repeat these steps in cycles before, during contralateral arm to where the injection will be administered) and after the procedure until they have no prodromal symptoms. for 15 to 30 seconds until they feel flushed or warm in the face. Next, they release the tension for 15 to 30 seconds, but they do It is critical to differentiate anaphylaxis from a DNSR (1). (The WHO ISRR guidance manual contains a table that can help
Page 214 CCDR • June 4, 2020 • Vol. 46 No. 6 CANVax - www.canvax.ca SERIES healthcare providers distinguish between anaphylaxis and be due to shared beliefs and contagion of anxiety and fear an ISRR (29)). If an individual loses consciousness following (36–39). These “clusters” have been known as “mass a vaccination, it could be a result of vasovagal syncope or psychogenic illness” or “mass hysteria” and have been reported anaphylaxis. Anaphylaxis is potentially life-threatening and inside and outside the immunization context (21,40). These requires medication (30). While the recipient is in the recovery terms can be inflammatory and demeaning to the affected position (supine, on their side), a healthcare provider should individuals (1). monitor the recipient’s pulse, respiration, blood pressure and peripheral circulation (1), watch their skin for rash or swelling and Trying to complete a mass vaccination campaign in a short listen to their lungs for wheeze or stridor. amount of time is a risk factor for the development of ISRR (1). The biopsychosocial framework is used to understand clusters, If an ISRR has been identified, it is important to communicate with particular attention paid toward understanding and that the response is not due to a vaccine product or procedural managing social factors. Known clusters in the immunization error; that the response is a known event that staff resolve by context have occurred in adolescents and adults but not in following specific guidance; and that the response can resolve infants and young children (1). Anaphylaxis is rare and extremely spontaneously without medication or hospitalization. unlikely to occur in clusters (1). If an ISRR cluster occurs, the affected individuals should be separated from others and each A DNSR that occurs following an immunization does not causally other to enable containment and appropriate management (1). implicate either the immunization or the immunization process. A The general strategies outlined above (i.e. training of staff, specific assessment is used to determine causality (6); the WHO communication, environmental modifications, screening for ISRR guidance manual provides a list that can help to diagnose people at risk for ISRR and targeted strategies such as privacy) a DNSR. Examples include symptoms that are inconsistent with are also critical in mass immunization contexts. Community known disorders and inconsistent presentation of symptoms leaders and healthcare providers who are known to the recipients (e.g. that disappear inexplicably or do not respond typically to can help keep them calm and comfortable. Educational materials interventions) (31). Nonepileptic seizures are one example of a such as posters differentiating anaphylaxis from ISRR and DNSR; these resemble epileptic seizures but do not have neural epileptic seizures from nonepileptic seizures could be designed discharges in the way epileptic seizures do (epileptic seizures and posted in the clinic (1). are differentiated from nonepileptic seizures in the WHO ISRR guidance manual (32)). Nonepileptic seizures are typically a diagnosis of exclusion (33). Although an electroencephalogram is Conclusion the gold standard assessment for seizures, conducting one may not be practicable. In summary, ISRRs are the redefined way to think about, identify and manage what was previously known as AEFI stemming A DNSR may resolve spontaneously or may require the from “anxiety” related to the immunization. ISRRs can occur involvement of a multidisciplinary team including a mental health before, during or after the immunization and are not due to professional. The biopsychosocial framework that is used to the vaccine product itself or an error in the process. Prevention understand ISRR should also guide treatment (1). Medical and strategies include proactive communication, managing social psychological expertise is needed for further assessment and media use and in-clinic environmental strategies. Screening can management to reduce functional disability. Treatment is specific identify those with increased risk of an ISRR, including those with to the presenting symptoms but may include physiotherapy, high levels of needle fear or with previous vasovagal reaction. cognitive behavioural therapy and/or pharmacological strategies Age‑appropriate pain management strategies should be (34,35). In the short term, the healthcare providers at the standard for all immunization recipients. Targeted interventions immunization clinic should attempt to put the affected individual for those experiencing an ISRR include muscle tension for and others present at ease. They should note that anxiety about vasovagal reactions, reducing vaccine recipients’ fear, increasing and fear of immunization are normal and can result in a bodily comfort and avoiding the contagion of fear and misinformation. response that may seem extreme but can resolve spontaneously without any injury (1). The affected individual should be kept Understanding the nature of ISRRs and their occurrence in a separate, calm, quiet space with only key people present. provides an opportunity for their prevention and appropriate The healthcare providers can answer the questions raised by the management, warding off future negative reactions towards affected individual and/or their caregiver(s). If the recipient and immunization and health care in general, and contributing to caregiver(s) are relatively calm, they may be able to be distracted sustaining trust in vaccines. The ISRR should be reported as part by talking about something else or listening to music to further of AEFI surveillance. calm them. The goal is to encourage return to normal activity (1). See the WHO ISRR guidance manual for further information (1) Similar or identical symptoms appearing in more than one person and the CANVax website for updates. with no physiological cause have been the source of attention and curiosity for hundreds of years; the “spread” is thought to
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